Four Steps

Dr. Jeffrey Schwartz's Four Steps

If you have obsessive thoughts and compulsive behaviors, you
will be relieved to learn of significant advances in the treatment
of this condition. Over the past twenty years, behavior therapy has
been shown to be extremely effective in treating
obsessive-compulsive disorder (OCD).

The concept of self-treatment as part of a behavioral therapy
approach is a major advance. In this manual, I will teach you how
to become your own behavioral therapist. By learning some basic
facts about OCD, and recognizing that it is a medical condition
that responds to treatment, you will be able to overcome the urges
to do compulsive behaviors and will master new ways to cope with
bothersome, obsessive thoughts.

At UCLA, we call this approach "cognitive-biobehavioral
self-treatment." The word cognitive is from the Latin word "to
know"; knowledge plays an important role in this approach to
teaching basic behavior therapy techniques. Research has shown that
exposure and response prevention are very effective behavior
therapy techniques for treating OCD. In traditional exposure and
response prevention, people with OCD learn--under the continuing
guidance of a professional therapist--to expose themselves to
stimuli that intensify their obsessive thoughts and compulsive
urges and then learn how to resist responding to those thoughts and
urges in a compulsive manner. For example, people who obsess
irrationally about contamination from dirt may be instructed to
hold something dirty in their hands and then not wash for at least
three hours. We've made some modifications in this method to allow
you to do it on your own.

The technique is called response prevention because you learn
to prevent your habitual compulsive responses and to replace them
with new, more constructive behaviors. We call our method
"biobehavioral" because we use new knowledge about the biological
basis of OCD to help you control your anxious responses and to
increase your ability to resist the bothersome symptoms of OCD. Our
treatment differs from classic exposure and response prevention in
one important way: We have developed a four-step method that
enhances your ability to do exposure and response prevention on
your own without a therapist being present.

The basic principle is that by understanding what these
thoughts and urges really are, you can learn to manage the fear and
anxiety that OCD causes. Managing your fear, in turn, will allow
you to control your behavioral responses much more effectively. You
will use biological knowledge and cognitive awareness to help you
perform exposure and response prevention on your own. This strategy
has four basic steps:

Step 1: Relabel
Step 2: Reattribute
Step 3: Refocus
Step 4: Revalue

The goal is to perform these steps daily. (The first three
steps are especially important at the beginning of treatment.)
Self-treatment is an essential part of this technique for learning
to manage your responses to OCD on a day-to-day basis. Let's begin
by learning the Four Steps.

Step 1: Relabel

The critical first step is to learn to recognize obsessive
thoughts and compulsive urges. You don't want to do this in a
merely superficial way; rather, you must work to gain a deep
understanding that the feeling that is so bothersome at the moment
is an obsessive feeling or a compulsive urge. To do so, it is
important to increase your mindful awareness that these intrusive
thoughts and urges are symptoms of a medical disorder.

Whereas simple, everyday awareness is almost automatic and
usually quite superficial, mindful awareness is deeper and more
precise and is achieved only through focused effort. It requires
the conscious recognition and mental registration of the obsessive
or compulsive symptom. You should literally make mental notes, such
as, 'This thought is an obsession; this urge is a compulsive urge."
You must make the effort to manage the intense biologically
mediated thoughts and urges that intrude so insistently into
consciousness. This means expending the necessary effort to
maintain your awareness of what we call the Impartial Spectator,
the observing power within us that gives each person the capacity
to recognize what's real and what's just a symptom and to fend off
the pathological urge until it begins to fade and recede.

The goal of Step 1 is to learn to Relabel intrusive thoughts
and urges in your own mind as obsessions and compulsions~and to do
so assertively. Start calling them that; use the labels obsession
and compulsion. For example, train yourself to say, "I don't think
or feel that my hands are dirty. I'm having an obsession that my
hands are dirty." Or, "I don't feel that I have the need to wash my
hands. I'm having a compulsive urge to perform the compulsion of
washing my hands." (The technique is the same for other obsessions
and compulsions, including compulsive checking of doors or
appliances and needless counting.) You must learn to recognize the
intrusive, obsessive thoughts and urges as OCD.

In the Relabeling step, the basic idea is: Call an obsessive
thought or compulsive urge what it really is. Assertively Relabel
it so you can begin to understand that the feeling is just a false
alarm, with little or no basis in reality. As the result of much
scientific research we now know that these urges are caused by
biological imbalances in the brain. By calling them what they
really are--obsessions and compulsions--you begin to understand
that they do not really mean what they say. They are simply false
messages coming from the brain.

It is important to remember that just Relabeling these thoughts
and urges won't make them go away. In fact, the worst thing you can
do is to try to make them vanish. It won't work because the
thoughts and urges have a biological cause that is beyond your
control. What you can control is your behavioral response to those
urges. By Relabeling, you begin to understand that no matter how
real they feel, what they are saying is not real. The goal: to
learn to resist them.

Recent scientific research on OCD has found that by learning to
resist obsessions and compulsions through behavior therapy, you can
actually change the biochemistry that is causing the OCD symptoms.
But keep in mind that the process of changing the underlying
biological problem, and by doing so changing the urge itself, may
take weeks or even months. It requires patience and persistent
effort. Trying to make these thoughts and urges go away in seconds
or minutes will cause only frustration, demoralization, and stress.
It will, in fact, tend to make the urges worse. Probably the most
important thing to learn in this behavioral treatment is that your
responses to the thoughts and urges are within your control, no
matter how strong and bothersome they may be. The goal is to
control your responses to the thoughts and urges, not to control
the thoughts and urges themselves.

The next two steps are designed to help you learn new ways to
control your behavioral responses to OCD symptoms.

Step 2: Reattribute

The key to our self-directed behavioral therapy approach to
treating OCD can be summed up in one sentence: "It's not me--it's
my OCD." That is our battle cry. It is a reminder that OCD thoughts
and urges are not meaningful, that they are false messages from the
brain. Self-directed behavior therapy lets you gain a deeper
understanding of this truth.

You are working toward a deep understanding of why the urge to
check that lock or why the thought that "my hands are dirty" can be
so powerful and overwhelming. If you know the thought makes no
sense, why do you respond to it? Understanding why the thought is
so strong and why it won't go away is the key to increasing your
willpower and enabling you to fight off the urge to wash or
check.

The goal is to learn to Reattribute the intensity of the
thought or urge to its real cause, to recognize that the feeling
and the discomfort are due to a biochemical imbalance in the brain.
It is OCD--a medical condition. Acknowledging it as such is the
first step toward developing a deeper understanding that these
symptoms are not what they seem to be. You learn not to take them
at face value.

Deep inside the
brain lies a structure called the caudate nucleus. Scientists
worldwide have studied this structure and believe that, in people
with OCD, the caudate nucleus may be malfunctioning. Think of the
caudate nucleus as a processing center or filtering station for the
very complicated messages generated by the front part of the brain,
which is probably the part used in thinking, planning, and
understanding. Together with its sister structure, the putamen,
which lies next to it, the caudate nucleus functions like an
automatic transmission in a car. The caudate nucleus and the
putamen, which together are called the striatum, take in messages
from very complicated parts of the brain--those that control body
movement, physical feelings, and the thinking and planning that
involve those movements and feelings. They function in unison like
an automatic transmission, assuring the smooth transition from one
behavior to another. Typically, when anyone decides to make a
movement, intruding movements and misdirected feelings are filtered
out automatically so that the desired movement can be performed
rapidly and efficiently. There is a quick, smooth shifting of
gears.

During a normal day, we make many rapid shifts of behavior,
smoothly and easily and usually without thinking about them. It is
the functioning of the caudate nucleus and the putamen that makes
this possible. In OCD, the problem seems to be that the smooth,
efficient filtering and the shifting of thoughts and behavior are
disrupted by a glitch in the caudate nucleus.

As a result of this malfunction, the front of the brain becomes
overactive and uses excessive energy. It's like having your car
stuck in a ditch. You spin and spin and spin your wheels, but
without traction you can't get out of that ditch. With OCD, too
much energy is being used in a frontal part of the brain called the
orbital cortex. It's as if the orbital cortex, which has an
error-detection circuit, becomes stuck in gear. This is probably
why OCD causes people to get a "something is wrong" feeling that
won't go away. You have to do the work to get it out of gear--to
shift the gears. You have a manual, rather than an automatic,
transmission. In fact, the person with OCD has a sticky manual
transmission; he or she must shift the gears. This takes great
effort because the brain tends to get "stuck in gear." But, whereas
an automobile transmission is made of metal and can't fix itself
people with OCD can teach themselves how to shift gears through
self-directed behavior therapy. In doing so, they can actually fix
this broken gearshift in the brain. We now know that you can change
your own brain biochemistry.

The key to the Reattribute step is to realize that the awful
intrusiveness and ferocious intensity of OCD thoughts are due to a
medical condition. Underlying problems in brain biochemistry are
causing these thoughts and urges to be so intrusive. That is why
they won't go away. By doing this Four-Step Method of self-directed
behavior therapy, you can change the brain's biochemistry. This
takes weeks or even months of hard work. In the meantime,
understanding the role the brain plays in OCD thoughts and urges
will help you to avoid one of the most demoralizing and destructive
things people with OCD almost invariably do: the frustrating
attempt to "get rid of" the thoughts and urges. There is nothing
you can do to make them go away immediately. But remember: You
don't have to act on them. Don't take them at face value. Don't
listen to them. You know what they are. They are false messages
from the brain that are due to a medical condition called OCD. Use
this knowledge to avoid acting on them. The most effective thing
you can do something that will help you change your brain for the
better in the long run--is to learn to put these thoughts and
feelings aside and go on to the next behavior. This is what we mean
by shifting gears: Do another behavior. Trying to make them go away
will only pile stress on stress--and stress just makes OCD thoughts
and urges worse.

Using the Reattribute step will also help you to avoid
performing rituals in a vain attempt to "get the right feeling"
(for example, a sense of "evenness" or a sense of completion).
Knowing that the urge to get that "right feeling" is caused by a
biochemical imbalance in the brain, you can learn to ignore the
urge and move on. Remember, "It's not me--it's my OCD." By refusing
to listen to the urge or to act on it, you will actually change
your brain and make the feeling lessen. If you take the urge at
face value and act on it, you may get momentary relief but within a
very short time the urge will just get more intense. This is
perhaps the most important lesson that people with OCD must learn.
It will help you avoid being the "sucker" and taking the false bait
of OCD every time.

The Relabel and Reattribute steps are usually performed
together to bring about a deeper understanding of what is really
happening when an OCD thought or urge causes you such intense pain.
You Relabel it, call it what it is--an obsession or a compulsion.
Use mindful awareness to get beyond a superficial understanding of
OCD and to gain the more profound understanding that the thoughts
and urges are nothing more than fallout from a medical
condition.

Step 3: Refocus

The Refocus step is where the real work is done. In the
beginning, you may think of it as the "no pain, no gain" step.
Mental exercise is like a physical workout. In Refocusing, you have
work to do: You must shift the gears yourself. With effort and
focused mindfulness, you are going to do what the caudate nucleus
normally does easily and automatically, which is to let you know
when to switch to another behavior. Think of a surgeon scrubbing
his hands before surgery: The surgeon doesn't need to wait for a
timer to go off to know when it's time to stop scrubbing. After a
while, the behavior is simply automatic. After a while he gets a
"feel" for when he's scrubbed enough. But people with OCD can't get
the feeling that something is done once it's done. The automatic
pilot is broken. Fortunately, doing the Four Steps can usually fix
it.

In Refocusing, the idea is to work around the OCD thoughts and
urges by shifting attention to something else, if only for a few
minutes. Early on, you may choose some specific behavior to replace
compulsive washing or checking. Any constructive, pleasant behavior
will do. Hobbies are particularly good. For example, you may decide
to take a walk, exercise, listen to music, read, play a computer
game, knit, or shoot a basketball.

When the thought comes, you first Relabel it as an obsessive
thought or a compulsive urge and then Reattribute it to the fact
that you have OCD--a medical problem. Then Refocus your attention
to this other behavior that you have chosen. Start the process of
Refocusing by refusing to take the obsessive-compulsive symptoms at
face value. Say to yourself, "I'm experiencing a symptom of OCD. I
need to do another behavior."

You must train yourself in a new method of responding to the
thoughts and urges, redirecting your attention to something other
than the OCD symptoms. The goal of treatment is to stop responding
to the OCD symptoms while acknowledging that, for the short term,
these uncomfortable feelings will continue to bother you. You begin
to "work around" them by doing another behavior. You learn that
even though the OCD feeling is there, it doesn't have to control
what you do. You make the decision about what you're going to do,
rather than respond to OCD thoughts and urges as a robot would. By
Refocusing, you reclaim your decision-making power. Those
biochemical glitches in your brain are no longer running the
show.

The Fifteen-Minute Rule

Refocusing isn't easy. It would be dishonest to say that
dismissing the thoughts and urges and moving on does not take
significant effort and even tolerance of some pain. But only by
learning to resist OCD symptoms can you change the brain and, in
time, decrease the pain. To help you manage this task, we have
developed the fifteen-minute rule. The idea is to delay your
response to an obsessive thought or to your urge to perform a
compulsive behavior by letting some time elapse--preferably at
least fifteen minutes--before you even consider acting on the urge
or thought. In the beginning or whenever the urges are very
intense, you may need to set a shorter waiting time, say five
minutes, as your goal. But the principle is always the same: Never
perform the compulsion without some time delay. Remember, this is
not a passive waiting period. It is a time to perform actively the
Relabeling, Reattributing, and Refocusing steps. You should have
mindful awareness that you are Relabeling those uncomfortable
feelings as OCD and Reattributing them to a biochemical imbalance
in the brain. These feelings are caused by OCD; they are not what
they seem to be. They are faulty messages coming from the
brain.

Then you must do another behavior~any pleasant, constructive
behavior will do. After the set period has lapsed, reassess the
urge. Ask yourself if there's been any change in intensity and make
note of any change. Even the smallest decrease may give you the
courage to wait longer. You will be learning that the longer you
wait, the more the urge will change. The goal will always be
fifteen minutes or more. As you keep practicing, the same amount of
effort will result in a greater decrease in intensity. So, in
general, the more you practice the fifteen-minute rule, the easier
it gets. Before long, you may make it twenty minutes or thirty
minutes or more.

It's What You Do That Counts

It is vitally important to Refocus attention away from the urge
or thought and onto any other reasonable task or activity. Don't
wait for the thought or feeling to go away. Don't expect it to go
away right away. And, by all means, don't do what your OCD is
telling you to do. Rather, engage in any constructive activity of
your choosing. You'll see that instigating a time delay between the
onset of the urge and even considering acting on it will make the
urge fade and change. What is more important, even if the urge
changes hardly at all, as sometimes happens, you learn that you can
have some control over your response to this faulty message from
the brain.

This application of mindful awareness and the Impartial
Spectator will be empowering to you, especially after years of
feeling at the mercy of a bizarre and seemingly inexplicable force.
The long-range goal of the Refocus step is, of course, never again
to perform a compulsive behavior in response to an OCD thought or
urge. But the intermediate goal is to impose a time delay before
performing any compulsion. You're learning not to allow OCD
feelings to determine what you do.

Sometimes the urge will be too strong, and you will perform the
compulsion. This is not an invitation to beat yourself up. Keep in
mind: As you do the Four Steps and your behavior changes, your
thoughts and feelings will also change. If you give in and perform
a compulsion after a time delay and an attempt to Refocus, make a
special effort to continue to Relabel the behavior and to
acknowledge that this time the OCD overwhelmed you. Remind yourself
"I'm not washing my hands because they are dirty, but because of my
OCD. The OCD won this round, but next time I'll wait longer." In
this way, even performing a compulsive behavior can contain an
element of behavior therapy. This is very important to realize:
Relabeling a compulsive behavior as a compulsive behavior is a form
of behavior therapy and is much better than doing a compulsion
without making a clear mental note about what it is.

A tip for those who are fighting checking behaviors--checking
locks, stoves, and other appliances: If your problem is, say,
checking the door lock, try to lock the door with extra attention
and mindful awareness the first time. This way, you'll have a good
mental picture to refer to when the compulsive urge arises.
Anticipating that the urge to check is going to arise in you, you
should lock the door the first time in a slow and deliberate
manner, making mental notes, such as "The door is now locked. I can
see that the door is locked." You want a clear mental image of that
locked door; so when the urge to check the door seizes you, you
will be able to Relabel it immediately and say, "That's an
obsessive idea. It is OCD." You will Reattribute the intensity and
intrusiveness of the urge to check again to your OCD. You will
remember, "It's not me--it's just my brain."

You will Refocus and begin to "work around" the OCD urges by
doing another behavior, with a ready mental picture of having
locked that door because you did it so carefully and attentively
the first time. You can use that knowledge to help you Refocus
actively on doing another behavior, even as you Relabel and
Reattribute the urge to check that has arisen, as you anticipated
it would.

Keeping a Journal

It is important to keep a behavior-therapy journal as a record
of your successful Refocusing efforts. It need not be anything
fancy. The idea is simply to have a written record to remind you of
your successes in self-directed behavior therapy. The journal is
important because you can refer back to it to see which behaviors
most helped you to Refocus. But--and this is equally important--it
helps you to build confidence as you see your list of achievements
grow. In the heat of battle against a compulsive urge, it isn't
always easy to remember which behavior to Refocus on. Keeping a
journal will help you to shift gears when the going gets tough,
when the obsessive thought or compulsive urge heats up, and will
train your mind to remember what has worked in the past. As your
list of successes gets longer, it will be inspirational.

Record only your successes. There is no need to record your
failures. You have to learn to give yourself a pat on the back.
This is something people with OCD need to learn to do more of. Make
sure to give yourself encouragement by consciously acknowledging
your successful use of Refocusing behaviors as a job well done.
Reinforce that success by recording it in your behavior-therapy
journal and giving yourself a little reward, even if it's only to
tell yourself how terrific you are for working so hard to help
yourself.

Step 4: Revalue

The goal of the first three steps is to use your knowledge of
OCD as a medical condition caused by a biochemical imbalance in the
brain to help you clarify that this feeling is not what it appears
to be and to refuse to take the thoughts and urges at face value,
to avoid performing compulsive rituals, and to Refocus on
constructive behaviors. You can think of the Relabel and
Reattribute steps as a team effort, working together with the
Refocusing step. The combined effect of these three steps is much
greater than the sum of their individual parts. The process of
Relabeling and Reattributing intensifies the learning that takes
place during the hard work of Refocusing. As a result, you begin to
Revalue those thoughts and urges that, before behavior therapy,
would invariably lead you to perform compulsive behaviors. After
adequate training in the first three steps, you are able in time to
place a much lower value on the OCD thoughts and urges.

We have used the concept of the "Impartial Spectator,"
developed by 18th-century philosopher Adam Smith, to help you
understand more clearly what you are actually achieving while
performing the Four Steps of cognitive biobehavioral therapy. Smith
described the Impartial Spectator as being like a person inside us
who we carry around at all times, a person aware of all our
feelings, states, and circumstances. Once we make the effort to
strengthen the Impartial Spectator's perspective, we can call up
our own Impartial Spectator at any time and literally watch
ourselves in action. In otherwords, we can witness our own actions
and feelings as someone not involved would, as a disinterested
observer. As Smith described it, "We suppose ourselves the
spectators of our own behavior." He understood that keeping the
perspective of the Impartial Spectator clearly in mind, which is
essentially the same as using mindful awareness, is hard work,
especially under painful circumstances, and requires the "utmost
and most fatiguing exertions.". The hard work of which he wrote
seems closely related to the intense efforts you must make in
performing the Four Steps.

People with OCD must work hard to manage the biologically
induced urges that intrude into conscious awareness. You must
strive to maintain awareness of the Impartial Spectator, the
observing power within that gives you the capacity to fend off
pathological urges until they begin to fade. You must use your
knowledge that OCD symptoms are just meaningless signals, false
messages from the brain, so you can Refocus and shift gears. You
must gather your mental resources, always keeping in mind, "It's
not me--it's my OCD. It's not me--it's just my brain." Although in
the short run, you can't change your feelings, you can change your
behavior. By changing your behavior, you find that your feelings
also change in time. The tug-of-war comes down to this: Who's in
charge here, you or OCD? Even when the OCD overwhelms you, and you
give in and perform the compulsion, you must realize that it's just
OCD and vow to fight harder the next time.

With compulsive behaviors, simply observing the fifteen-minute
rule with consistency and Refocusing on another behavior will
usually cause the Revalue step to kick in, which means realizing
that the feeling is not worth paying attention to and not taking it
at face value, remembering that it's OCD and that it is caused by a
medical problem. The result is that you place a much lower value
on--devalue--the OCD feeling. For obsessive thoughts, you must try
to enhance this process by Revaluing in an even more active way.
Two substeps--the two A's--aid you in Step 2: Reattribute:
Anticipate and Accept. When you use these two A's, you are doing
Active Revaluing. Anticipate means "be prepared," know the feeling
is coming, so be ready for it; don't be taken by surprise. Accept
means don't waste energy beating yourself up because you have these
bad feelings. You know what's causing them and that you have to
work around them. Whatever the content of your obsession--whether
it is violent or sexual or is manifested in one of dozens of other
ways--you know that it can occur hundreds of times a day. You want
to stop reacting each time as though it were a new thought,
something unexpected. Refuse to let it shock you; refuse to let it
get you down on yourself. By anticipating your particular obsessive
thought, you can recognize it the instant it occurs and Relabel it
immediately. You will simultaneously, and actively, Revalue it.
When the obsession occurs, you will be prepared. You will know,
"That's just my stupid obsession. It has no meaning. That's just my
brain. There's no need to pay attention to it." Remember: You can't
make the thought go away, but neither do you need to pay attention
to it. You can learn to go on to the next behavior. There is no
need to dwell on the thought. Move ahead. This is where the second
A--Accept--comes in. Think of the screaming car alarm that disturbs
and distracts you. Don't dwell on it. Don't say, "I can't do
another thing until that blankety-blank car alarm shuts off."
Simply try to ignore it and get on with things.

You learned in Step 2 that the bothersome obsessive thought is
caused by OCD and is related to a biochemical imbalance in the
brain. In the Acceptance substep of Reattributing, you realize that
truth in a very deep, perhaps even spiritual, way. Do not get down
on yourself. it makes no sense to criticize your inner motives just
because of an imbalance in the brain. By accepting that the
obsessive thought is there despite you, not because of you, you can
decrease the terrible stress that repetitive obsessive thoughts
usually cause. Always keep in mind, "It's not me--it's the OCD.
It's not me--it's just my brain." Don't beat yourself up trying to
make the thought go away because in the short run, it will not.
Most important, don't ruminate and don't fantasize about the
consequences of acting out a terrible obsessive thought. You won't
act it out because you don't really want to. Let go of all the
negative, demeaning judgments about "the kinds of people who get
thoughts like this." For obsessions, the fifteen-minute rule can be
shortened to a one minute rule, even a fifteen-second rule. There
is no need to dwell on that thought, even though it lingers in your
mind. You can still go on--indeed, you must go on--to the next
thought and the next behavior. In this way, Refocusing is like a
martial art. An obsessive thought or compulsive urge is very
strong, but also quite stupid. If you stand right in front of it
and take the full brunt of its power, trying to drive it from your
mind, it will defeat you every time. You have to step aside, work
around it, and go on to the next behavior. You are learning to keep
your wits about you in the face of a powerful opponent. The lesson
here goes far beyond overcoming OCD By taking charge of your
actions, you take charge of your mind--and of your life.

Conclusion

We who have OCD must learn to train our minds not to take
intruding feelings at face value. We have to learn that these
feelings mislead us. In a gradual but tempered way, we're going to
change our responses to the feelings and resist them. We have a new
view of the truth. In this way, we gain new insights into the
truth. We learn that even persistent, intrusive feelings are
transient and impermanent and will recede if not acted on. And, of
course, we always remember that these feelings tend to intensify
and overwhelm us when we give in to them. We must learn to
recognize the urge for what it is--and to resist it. In the course
of performing this Four-Step Method of behavioral self-treatment,
we are laying the foundation for building true personal mastery and
the art of self-command. Through constructive resistance to OCD
feelings and urges, we increase our self-esteem and experience a
sense of freedom. Our ability to make conscious, self-directed
choices is enhanced.

By understanding this process by which we empower ourselves to
fight OCD and by clearly appreciating the control one gains by
training the mind to overcome compulsive or automatic responses to
intrusive thoughts or feelings, we gain a deepening insight into
how to take back our lives. Changing our brain chemistry is a happy
consequence of this life-affirming action. True freedom lies along
this path of a clarified perception of genuine self-interest.

QUICK SUMMARY OF THE FOUR STEPSOF COGNITIVE BIOBEHAVIORAL
SELF-TREATMENT FOR OCD

Step 1: RELABEL
Recognize that the intrusive obsessive thoughts and urges are the
RESULT OF OCD.

Step 2: REATTRIBUTE
Realize that the intensity and intrusiveness of the thought or urge
is CAUSED BY OCD; it is probably related to a biochemical imbalance
in the brain.

Step 3: REFOCUS
Work around the OCD thoughts by focusing your attention on
something else, at least for a few minutes: DO ANOTHER
BEHAVIOR.

Step 4: REVALUE
Do not take the OCD thought at face value. It Is not significant in
itself.

About Dr. Eda Gorbis

Eda Gorbis, PhD, LMFT, is the Director/Founder of the Westwood Institute for Anxiety Disorders, Inc., and an Adjunct Clinical Assistant Professor of Psychiatry & Biobehavioral Sciences at the USC Keck School of Medicine. From 1999 and until 2014 Dr. Gorbis held an appointment of Assistant Clinical Professor in the Department of Psychiatry at the UCLA School of Medicine. She specializes in treatment of refractory cases of OCD and has integrated the most successful treatment modalities for OCD and complex comorbidities.